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Informe especial / Special report

Rev Panam Salud Publica

32(4), 2012301

Levings J, Cogswell M, Curtis CJ, Gunn J, Neiman A, Angell SY. Progress toward sodium reduction inthe United States. Rev Panam Salud Publica. 2012;32(4):3016.

Suggested citation

Progress toward sodium reductionin the United States

Jessica Levings,1 Mary Cogswell,1 Christine J. Curtis,2

Janelle Gunn,1 Andrea Neiman,1 and Sonia Y. Angell1

The average adult in the United States of America consumes well above the recommendeddaily limit of sodium. Average sodium intake is about 3 463 mg/day, as compared to the 2010dietary guidelines for Americans recommendation of < 2 300 mg/day. A further reductionto 1 500 mg/day is advised for people 51 years or older; African Americans; and people withhigh blood pressure, diabetes, or chronic kidney disease. In the United States of America, theproblem of excess sodium intake is related to the food supply. Most sodium consumed comes

from packaged, processed, and restaurant foods and therefore is in the product at the time ofpurchase. This paper describes sodium reduction policies and programs in the United Statesat the federal, state, and local levels; efforts to monitor the health impact of sodium reduction;ways to assess consumer knowledge, attitudes, and behavior; and how these activities dependon and inform global efforts to reduce sodium intake. Reducing excess sodium intake is a publichealth opportunity that can save lives and health care dollars in the United States and glob-ally. Future efforts, including sharing successes achieved and barriers identified in the United

States and globally, may quicken and enhance progress.

Sodium; world health; United States.

abstract

Key words

The average adult and child in theUnited States of America consume wellabove the recommended daily limit ofsodium. Average sodium intake is 3 463mg/day (1) (Figure 1), as compared tothe 2010 dietary guidelines for Americansrecommendation of < 2 300 mg/day.A further reduction to 1 500 mg/day

is advised for people 51 years or older;African Americans; and people withhigh blood pressure, diabetes, or chronickidney disease (2). These populations

account for about half of the U.S. popula-tion and the majority of adults (3).

High sodium consumption increasesblood pressure, raising hypertensionrates and the risk for cardiovascular dis-ease and early death. Globally, hyperten-sion is a leading risk factor for mortality(4). Currently, one-third of U.S. adults

have hypertension, which was a primaryor contributing cause of approximately348 000 U.S. deaths in 2008 (5). Reduc-ing average daily sodium intake in thepopulation by 400 mg could avert upto 28 000 deaths from any cause andcould save $7 billion in annual healthcare expenditures in the United States(6). Achieving this reduction is feasible;a 25% reduction in sodium content of

the top 10 food category contributorsto sodium intake could result in an 11%reduction (approximately 360 mg) inaverage daily sodium consumption inthe United States (7). Despite the strong

body of evidence supporting sodiumreduction as a means to save lives andhealth care costs, as is common with

policy making, some individuals havequestioned the evidence base for publicpolicy related to reduced sodium intakein the population (8).

In the United States, the problem ofexcess sodium intake is related to thefood supply. The majority of sodiumconsumed comes from packaged, pro-cessed, and restaurant foods (9) andtherefore is in the product at the time

1 Centers for Disease Control and Prevention, At-lanta, Georgia, United States of America. Sendcorrespondence to: Jessica Levings, [email protected]

2 New York City Department of Health and MentalHygiene, New York, New York, United States ofAmerica.

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Special report Levings et al. Progress toward sodium reduction in the United States

of purchase. In 2010, a report by the

Institute of Medicine, Strategies to re-duce sodium intake in the United States,recommended that the Food and DrugAdministration (FDA) set mandatorystepwise targets to lower the sodiumcontent of foods and that the food in-dustry voluntarily reduce the sodiumcontent of foods in the interim (10). Tosupport national initiatives, the Instituteof Medicine also recommended morewidespread implementation of state andlocal policies to reduce the amount of so-dium in foods served in restaurants andother food service establishments as well

as continued and enhanced monitoringof the impact of sodium reduction. TheAmerican Heart Association released aPresidential Advisory in 2011 urginga renewed and intensive focus onachieving population-wide reduction insodium intake.

This paper describes sodium reduc-tion policies and programs at the fed-eral, state, and local levels in the UnitedStates; efforts to monitor the health im-pact of sodium reduction; ways to assessconsumer knowledge, attitudes, and be-havior; and how these activities depend

on and inform global efforts to reducesodium intake.

Sodium reduction policieSand programS in theunited StateS

Calls for voluntary reductions of so-dium levels in the U.S. food supply have

been ongoing for > 40 years, but success

has been limited (10). Sodium intake

continues to exceed recommended lev-els, prompting an increased focus onsodium reduction at all levels of the U.S.government: national, state, and local.

n

At the federal level, packaged foodsare regulated primarily by the FDA(nearly 80% of the U.S. food supply).The United States Department of Agri-culture (USDA) regulates mostly meatand poultry (nearly 20% of the food sup-ply). While labeling of sodium content

on most packaged foods sold to con-sumers has been mandatory since 1993(11), labeling of single-ingredient andground and chopped meat and poultryproducts did not become mandatoryuntil 2012 (12). Regulations requiringlabeling for meat and poultry productsinjected with a sodium-containing solu-tion are under consideration (13). Ad-ditionally, for the first time, federal regu-lation from the FDA will require thatspecific types of restaurants and similarretail food establishments with 20 ormore locations provide information on

the sodium content of menu items (14).In 2011, the USDA and the U.S. Depart-ment of Health and Human ServicesFDA and Centers for Disease Controland Prevention (CDC) sponsored a pub-lic meeting, Approaches to ReducingSodium Consumption (15) to providean opportunity to comment on currentand emerging approaches to reducingsodium intake. Information obtained at

this meeting and comments received aspart of a public request for commentspublished in theFederal Register will helpinform future actions of federal regula-tory agencies.

Sodium reduction is a key componentof federal initiatives aiming to improvecardiovascular health, including Million

Hearts and Healthy People 2020. Mil-lion Hearts aims to prevent 1 millionheart attacks and strokes over the next5 years. A primary goal of the MillionHearts initiative is a reduction in popu-lation sodium intake of 20% by January 1,2017, through efforts such as introducingprocurement policies to increase accessto foods with lower sodium content, in-creasing public and professional educa-tion about the health effects of excesssodium, and collecting and sharing in-formation on sodium consumption (16).Healthy People 2020 provides science-

based, 10-year national objectives for im-proving the health of all Americans andaims to motivate improvements in health

by encouraging collaborations acrosscommunities and sectors, empoweringindividuals to make informed health de-cisions, and measuring the impact ofprevention activities. One Healthy People2020 objective for reducing sodium intakeis to reduce mean sodium intake by theU.S. population to 2 300 mg/day by 2020.Other examples of federal action are 2012rules issued by the USDA that reduce thesodium content of school lunches and

breakfasts throughout the country (17).The Department of Health and HumanServices and the General Services Admin-istration established guidelines for fed-eral vending and concessions that includesodium requirements (18).

Public health agencies and organiza-tions in the United States are also col-laborating to promote the importanceof sodium reduction through a nationaleffort. The National Salt Reduction Ini-tiative (NSRI) is a broad partnership of> 85 national and regional health organi-zations as well as local and state health

authorities from across the country.Launched in 2008 and coordinated bythe New York City Department of Healthand Mental Hygiene (NYC Health De-partment), the NSRI aims to lower thesodium intake of the U.S. population by20% over 5 years by reducing the sodiumcontent of packaged, processed, and res-taurant foods by 25% over that period(19). It is the first national strategy in

FIGURE 1. Mean sodium intake, by age and sex, National Health and Nutrition ExaminationSurvey,a United States, 20092010

0

500

1 000

1 500

2 000

2 5003 000

3 500

4 000

4 500

5 000

25 611 1219 2029 3039 4049 5059 6069 70 Adults( 20)

Overall

Age group (years)

Meansodiumi

ntak

e,

mg/day

Males

Females

a Reference 1.

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the Americas integrating a frameworkfor voluntary corporate commitments tosodium targets with a multilevel evalu-ation to capture change in the sodiumcontent of the food supply and in pop-ulation intake. The model of invitingindustry to publicly commit to sodiumtargets and report on industry achieve-

ments is based on the United Kingdomssalt reduction campaign, which pub-lished its first set of sodium targets in2005, to be met by 2008 (20). Through aniterative process of analyzing nutritionand sales data and soliciting feedbackfrom industry, the NSRI has set 2012and 2014 sodium targets for 62 packagedfood and 25 restaurant food categories,along with a maximum sodium level forrestaurant items (21, 22). To date, 28 foodmanufacturers, restaurant chains, andsupermarkets have publicly committedto meeting NSRI targets.3

S

State-level sodium reduction effortshave also been increasing. For example,the Massachusetts Department of Pub-lic Health implemented statewide foodstandards for food purchased and mealsprepared by specific state agencies (23).The Texas Salt Reduction Collaborativewas established in 2011 by the TexasCardiovascular Disease and Stroke Part-nership to provide a vehicle for membersand the public to receive information on

evidence-based programs, practices, andpolicies (24). The state health depart-ment in Indiana is providing procure-ment training to local business vendorsthat work with state agencies such asschools, jails, and hospitals on sodiumreduction in contracted food items.

l

Local jurisdictions are implementingpolicies and programs to reduce so-dium intake. In 2010, CDC launchedthe Sodium Reduction in Communities

Program to help create healthier foodenvironments by reducing sodium in-take. Five sites around the country werefunded to work with venues such asrestaurants, grocery stores, schools, andsenior centers to reduce the sodium con-tent of foods consumed and stocked, and

to spearhead changes in procurementpolicies (25).

Several U.S. cities are developing nu-trition standards for foods purchased,distributed, and sold. New York Citywas the first major U.S. city to intro-duce nutrition criteria that apply to allfoods purchased and served by the city.

The standards for foods purchased andserved by city agencies were introduced

by a mayoral executive order in 2008,followed by standards for beverage andfood vending machines in 2009 and 2011,respectively (26). The standards includesodium limits for individual food itemsand meals while addressing other nu-trient requirements, and cover daycarecenters, schools, correctional facilities,hospitals, and other venues run or con-tracted by municipal agencies. The stan-dards affect > 270 million meals andsnacks served each year to New Yorkers

and > 4 000 vending machines. Estab-lishing comprehensive nutrition stan-dards supports the goal of providinghealthful food to city clients and em-ployees, and uniform standards acrosscity agencies eased vendor compliance.The NYC Health Department is expand-ing this work to private venues by work-ing with retail food outlets in hospitalsand worksites, such as cafeterias.

monitoring Sodiumreduction

Monitoring the impact of efforts at thenational, state, and local levels will pro-vide data needed to determine successand inform future approaches. Key areasto monitor include the sodium contentof packaged, processed, and restaurantfoods as well as population sodium in-take using dietary and biomarker data.

To monitor the amount of sodium infoods, CDC is working with USDAs Ag-ricultural Research Service and the FDAto track primary contributors to sodiumintake (sentinel foods) over time and todetermine changes in sodium content.

Monitoring sodium and other nutrientcontents of these sentinel foods will pro-vide an early indication of how the foodsupply is changing and how consumersare responding and will focus furtherinvestigations and assessments. A vari-ety of additional approaches are beingused to monitor the amount of sodiumin foods, including developing a pack-aged food database (to monitor changes

within specific food groups); system-atically reviewing studies that evaluatethe sodium content of restaurant foodsto help determine the best system formonitoring; and using existing data toprovide reports on the contribution ofspecific foods to the sodium intake of thepopulation.

Maintaining current databases is chal-lenging because of the frequency of re-formulation and the introduction of newproducts in the marketplace. CDC iscollaborating with the USDA in efforts toupdate the nutrient values of select foodsin the USDA National Nutrient Databasefor Standard Reference. This databaseforms the basis for other nutrient data-

bases as well as for the development ofnutrition label information and nutritionclaims by manufacturers (27). Foods inthe database, including some restaurantfoods, will be updated based on con-

sumption frequency and sodium con-tent, as determined by National Healthand Nutrition Examination Survey data.To build capacity for monitoring nutri-ent content across additional foods and

brands and to assess the average andrange of sodium content of products,CDC is developing a packaged food da-tabase based on sentinel foods that makeup the top 80% of sales volume withinUSDA food categories, similar to thedatabase developed by the NYC HealthDepartment for the NSRI. The NSRI nu-trition databases allow for the analysis of

food nutrient content by food categoryand company over time. The NSRI Pack-aged Food Database merges sales andnutrition information for 62 packagedfood categories, and the NSRI Restau-rant Food Database uses market sharedata for the top 50 restaurant chains (bysales), merged with nutrition data, for25 restaurant food categories (28). Dataon average sodium content by categoryat baseline in 2009 are available online.4The databases are being updated in 2012to assess changes in the sodium contentof U.S. foods.

To better understand population in-take of sodium and related nutrients,the federal government collects and ana-lyzes a variety of data. One example is arecent study designed to update under-standing of the typical sources of dietarysodium intake (including sodium from

3 For more detail on the NSRI, go to nyc.gov/health/salt

4 Available from: http://www.nyc.gov/html/doh/downloads/pdf/cardio/cardio-salt-nsri-packaged.pdf

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diets and active lifestyles to ones in-creasingly characterized by consump-tion of packaged, processed, and res-taurant foods accompanied by physicalinactivity.7 For example, over the past 20years increased consumption of sugary

beverages, processed meats, and breadsand reduced consumption of rice, beans,

and other unprocessed ingredients havebeen reported in Brazil (38). This transi-tion has been facilitated partly by globalmigration into urban settings, with LatinAmerica experiencing one of the mostrapid demographic shifts from a largelyrural to a mostly urban society. An-other major contributor to urbanizationhas been globalization, with countries

becoming interconnected by economicgrowth and development (39). As a re-sult of both of these changes, many foodand beverage companies and food retail-ers in the United States have extended

their reach into world markets, so thatglobal and U.S. processed food marketsare increasingly similar and connected.

With this convergence comes opportu-nity. Lessons learned in the United Stateson reducing sodium in the food supplymay have increasing relevance in otherregions. This includes models at the na-tional and local levels for working withprivate industry, changing governmentprocurement practices, and institutingnutrition labeling. Conversely, becausemajor corporations producing in and forthe U.S. marketplace also manufacture

for other regions, actions undertaken toreduce the sodium content of packagedand processed foods in countries withinthis regional marketplace but outsidethe United States are likely relevant tothe United States. For example, breadis the largest contributor to sodium in-take in the United States. Mexican-ownedand -headquartered Grupo Bimbo, theworlds leading producer of bakery

brands and the fourth largest globalfood corporation, owns common U.S.household brand names such as SaraLee and Entenmanns. Technology used

by Grupo Bimbo to reduce the amountof sodium in its Mexican products couldserve as a reference for similar reductions

processed and restaurant foods, sodiuminherent in foods, and salt added at thetable and during cooking).

To monitor sodium intake, the CDC,National Institutes of Health, USDA, andFDA continue to collect and analyze 24-hour recall data on dietary sodium andrelated nutrients (e.g., potassium and io-

dine5) from the National Health and Nu-trition Examination Survey. Biomarkerdata may better capture all sources ofsodium intake (e.g., foods, salt added atthe table, medications) and can be moreaccurate than self-reports (29). Ongoingactivities include assessment of historicand spot urine specimens and previ-ously collected data to inform trendsin sodium and potassium intake. Newdata collection and analyses include spoturine specimens for estimating popula-tion sodium intake. Potential limitationsfor using spot urine specimens to esti-

mate population sodium intake includelarge diurnal variations in sodium excre-tion during the day, an increase in urinedilution overnight with aging, and thefact that specimens may not reflect thediet of the individual unless the diet isvery stable. CDC is assessing the poten-tial use of random (spot) urine collectionto estimate 24-hour sodium excretion atthe population level.

At the local level, the NYC HealthDepartment assessed sodium intake

based on a 24-hour urine collection from> 1 600 adult New Yorkers, weighted to

represent the New York City population.Called the Heart Follow-Up Study, itwas the first representative, population-

based study in the United States to assesssodium intake by this methodology. Keyvariables collected include an objectivemeasurement of sodium intake, seated

blood pressure, measured height andweight, and self-reported health and dietinformation, all of which are vital tounderstanding changes in sodium intakerelated to the NSRI and local efforts in

New York City (30). A full report of thefindings is pending, and follow-up as-sessment of population sodium intake inNew York City is planned.

aSSeSSing conSumerknowledge, attitudeS, andbehavior related to Sodium

reduction

Consumer awareness can drive actionaimed at reducing sodium intake. CDCmonitors knowledge, attitudes, and be-haviors pertaining to individual sodiumintake (3135). Additional questions toassess consumer behavior relating to so-dium intake will be incorporated in theBehavioral Risk Factor Surveillance Sys-tem to be conducted in 2013. CDC alsomonitors health care costs and healthoutcomes related to reduced sodium in-take. The Data Trends and Maps website

provides annual national- and state-leveldata on risk factors for cardiovasculardisease.6 In addition, CDC is workingwith academic partners to evaluate thecost-effectiveness of interventions de-signed to reduce sodium intake, modelthe impact of reduced sodium intake onmortality, and examine associations ofusual sodium intake with all-cause andcardiovascular disease deaths to furtherassess the health and economic impact ofreduced sodium intake (36).

Efforts to reduce sodium intake inthe United States have been increasing

yet are still fairly new; thus, evaluationefforts assessing the impact of theseprograms on population health remainunder development.

global relevance of effortSto reduce Sodium intake inthe united StateS

As described, efforts to reduce pop-ulation sodium intake in the UnitedStates are increasingly implemented atthe federal, state, and local levels, with aprimary focus on decreasing the amount

of sodium in packaged, processed, andrestaurant foods, the main sources ofsodium in the U.S. diet. The U.S. focusmay be increasingly relevant to manylow- and middle-income countries thathave experienced a nutrition transition(37), marked by a shift from traditional

5 While iodine deficiency disorders are less preva-

lent in the United States, they are a serious globalpublic health challenge and a leading cause ofpreventable childhood brain damage. To preventiodine deficiency disorders, universal salt iodiza-tion programs are supported by most countries,and voluntary use of fortified salt in prepackagedand processed foods is increasingly being encour-aged. It is plausible that the opportunity to reducesodium intake while increasing iodine fortificationcan be achieved if supported by the top food com-panies to positively affect global public health. Inthe United States, salt used in food processing isnot iodized.

6 Available from: http://apps.nccd.cdc.gov/NCVDSS_DTM/

7 Pan American Health Organization. The WHOglobal strategy on diet, physical activity, and health,implementation plan for Latin America and the Ca-ribbean 20062007 [unpublished document]. Wash-ington, D.C.: PAHO; 2006. Available from: http://apjcn.nhri.org.tw/server/APJCN/Volume10/vol10supp/Popkin.pdf Accessed 5 November 2012.

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in the United States. Further, innova-tions in the United States could provideinformation for reformulating Mexicanproducts. Lessons learned from nationalsurveillance of packaged, processed, andrestaurant foods may provide furtherinsight and opportunities for the UnitedStates and other countries. Packaged and

restaurant food databases in other coun-tries can be used to identify successfulsodium reductions in products also soldin the United States, potentially inform-

ing innovations in the United States andbeyond. Successful reduction of sodiumintake in one country creates the poten-tial for success in all countries.

cs

Reducing excess sodium intake is

a public health opportunity that cansave lives and health care dollars in theUnited States and globally. Innovativesodium reduction initiatives, and corre-

sponding improvements in monitoringand surveillance, are under way at alllevels of government across the UnitedStates. Future efforts, including sharingof successes achieved and barriers iden-tified in the United States and globally,may quicken and enhance progress.

disclaimer. The findings and con-clusions in this report are those of theauthors and do not necessarily representthe official position of the CDC.

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El adulto medio de los Estados Unidos consume una cantidad de sodio muy por encimadel lmite diario recomendado. La ingesta promedio de sodio es aproximadamente de3 463 mg/da, en contraste con la recomendacin de las Directrices alimentarias del2010 para estadounidenses que es de menos de 2 300 mg/da. A las personas de 51aos o mayores, los afroestadounidenses, los hipertensos, los diabticos o los quepadecen una nefropata crnica, se les recomienda una reduccin adicional hasta1 500 mg/da. En los Estados Unidos, el problema de la ingesta excesiva de sodio estrelacionado con el suministro en los alimentos. La mayor parte del sodio consumidoproviene de los alimentos envasados, procesados y que se sirven en restaurantes y,por consiguiente, ya est en el producto en el momento de la compra. Este artculodescribe las polticas y los programas de reduccin del sodio en los Estados Unidosa escalas federal, estatal y local; las iniciativas para vigilar la repercusin de la

reduccin del sodio en la salud; los procedimientos para evaluar los conocimientos,las actitudes y el comportamiento de los consumidores; y cmo estas actividadesdependen de las iniciativas a escala mundial para reducir la ingesta de sodio y lesproporcionan informacin. La reduccin de la ingesta excesiva de sodio constituyeuna oportunidad de salud pblica que puede salvar vidas y ahorrar dinero destinadoa la atencin de salud en Estados Unidos y a escala mundial. Las iniciativas futuras,entre ellas el intercambio de informacin sobre los xitos logrados y los obstculosencontrados en los Estados Unidos y a escala mundial, pueden acelerar y estimularel progreso.

Sodio; salud mundial; Estados Unidos.

resumen

Progresos hacia lareduccin del sodio en

los Estados Unidos

Palabras clave

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